COLORADO VETERANS COMMUNITY LIVING CTR AT HOMELAKE

A survey for Incident #34722 was conducted 2/13/24. One deficiency was cited.

Based on record review and staff interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of four sample residents was kept free from abuse. Resident #2 and Resident #1 were involved in an altercation on 11/7/23. Resident #2 attacked Resident #1 and Resident #1 had injuries that included a scratch to his left forehead that was cleaned, a scratch on his nose, an abrasion to his left face/cheek, left jawline, left ear and bruising to the top of his left shoulder. There was redness around his neck and Resident #1 complained of severe left shoulder pain. Interventions added after the altercation were to move Resident #2 to a different hall and the resident was to be in the staff's line of sight. However, those interventions were not effective due to another altercation that occurred on 1/3/24. According to Resident #1, on 1/3/24 Resident #2 pulled him down and hit him. Resident #2 had redness/possible bruising to the right hand at the base of the third finger knuckle and an abrasion on the back of his left hand. Resident #1 sustained a bloody nose, a skin tear to his nose and left hand and two abrasions to the forehead. He also sustained a fracture to one of the fingers on his right hand. Resident #1 was sent to the hospital for evaluation and treatment. The facility failed to implement measures to protect Resident #1 from abuse perpetrated by Resident #2, who was known to be physically aggressive. Findings include: I. Facility policy The Abuse policy, revised 10/16/23, was provided by the nursing home administrator (NHA) on 2/13/2024 at 4:05 p.m. It documented in pertinent part, "It is the policy of the (corporation) to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect and exploitation. The (facility) will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteer, contracted staff, family members, resident representatives, visitors, and other individuals." II. Resident-to-resident altercation involving Resident #1 and Resident #2 on 11/7/23 According to the investigation, Resident #2 entered the room that adjoined his and went to the bed where Resident #1 was sleeping and began attacking him. Resident #2 attempted to choke Resident #1 but the Resident #1 was able to make enough noise to alert staff of the situation. Staff reported a certified nurse aide (CNA) attempted to pull the Resident #2 from Resident #1 and when she did, Resident #2 pushed her away from him. The CNA called for assistance and when staff entered the room they were able to get the Resident #2 away from Resident #1 and out of the room. Resident #2 was brought to the rotunda (common area) where he slept for the next hour. The medical doctor (MD), the NHA, the director of nursing (DON), the social services staff and family were notified of the incident. Law enforcement was notified at 5:20 p.m. Resident #1 sustained a scratch to his left forehead that was cleaned, dried and covered with protective dressing. He had a scratch on his nose, an abrasion to his left face/cheek, left jaw line, left ear and bruising to the top of his left shoulder. There was redness around his neck and the resident complained of severe left shoulder pain. The facility's action for the assailant was to add Resident #2's behaviors to the care plan and implement an intervention for the resident to be in the line of sight of the staff. Resident #2 was moved to a different hall. The conclusion of the internal investigation documented Resident #2 attacked and choked Resident #1. Resident #1 did not remember the incident. The CNA witnessed the incident and separated the residents immediately. III. Resident-to-resident altercation involving Resident #1 and Resident #2 on 1/3/24 According to the investigation, there was an unwitnessed altercation between Resident #1 and Resident #2 on 1/3/24. Resident #1 thought Resident #2 may have punched him. The registered nurse (RN) in charge thought maybe Resident #1 attempted to stand up and fell and hit his nose and side of his head due to injury marks and where he was found. A CNA observed what she thought was a resident had fallen. Resident #1 was mostly out of his wheelchair next to the wall with Resident #2 holding him by his shirt collar. The CNA redirected Resident #2 down to his hallway and called a RN to assess injuries in both residents. Resident #1 was interviewed by a police officer and, due to the resident having an abrasion to head, he was sent to the emergency room for further evaluation. The nature of suspected abuse was physical with hitting and Resident #1 having a fractured finger. The facility's action for Resident #2 was for the resident to be in the line of sight of the staff. Resident #2 was moved to a room at the end of the hall. The facility documented the incident was inconclusive due to the cognition of the residents.-However, the CNA did witness the resident being pulled by his collar which caused the fall and injuries to Resident #1 (see progress notes below). In addition, Resident #2 had redness/possible bruising to the right hand at the base of the third finger knuckle and an abrasion on the back of his left hand. IV. Resident #1 A. Resident status Resident #1, age 87, was admitted on 5/15/23. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), dementia and age related physical disability, According to the 1/25/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had verbal and physical behaviors directed towards others. B. Resident observation and interview Resident #1 was interviewed on 2/13/24 at 9:50 a.m. Resident #1 was lying down in his bed looking out the window. He said he stayed in his room most of the time as he liked to spend time alone. Resident #1 said, "I don't want to talk about it but I tell you if I would not have been lying down I would have let him have it because I know martial arts." C. Record review The care plan, initiated 5/15/23 and revised 1/25/24, identified the resident had impaired cognition function/dementia or impaired thought processes and dementia with behaviors. Interventions included keeping resident's routine consistent and trying to provide consistent caregivers as much as possible and monitor/document/report as needed any changes in cognitive function, specifically changes in decision making ability. The nurse note dated 1/3/24 at 7:53 p.m. documented in pertinent part, "This nurse heard a CNA yelling for a nurse. Upon arrival to the hallway the resident was found lying on the floor with his head against the wall with nose bleeding, skin tear to nose and skin tear to left hand with two abrasions to the forehead. The resident was stating another resident made him fall and hit him. The resident complained of shoulder pain which was chronic. Administration and medical doctor notified with order to send the resident to the emergency room (ER) for evaluation. Social service notified as well as family of possible altercation. The Sheriff's office notified and came into the facility to interview residents. The ambulance arrived to transport to hospital. Report called to nurse at hospital. The resident was alert smiling and talking to emergency medical technicians (EMT). The EMT asked the resident if he hit his head and he stated, 'I don't remember as my memory isn't very good anymore'." The 72-hour follow up notes dated 1/4/24 at 6:31 a.m. documented in pertinent part, "The resident was back from hospital altercation with another resident. The resident received his tetanus shot, had some lacerations, bruising anda fracture to his finger on the right hand. The resident complained of pain and received medication without complications."The physician note dated 1/6/24 at 3:54 p.m. documented in pertinent part, "Follow up ER visit from 1/3/24. Unwitnessed incident resulted in skin tear, abrasions and fracture that is not displaced of the finger. Splint on for at least three weeks." V. Resident #2 A. Resident status Resident #2, age 76, was admitted on 7/22/22. According to the February 2024 CPO, diagnoses included dementia and adult failure to thrive. According to the 12/7/23 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident had no behavioral symptoms. B. Record review The care plan, initiated 7/22/22 and revised 12/7/23, identified the resident had potential to be physically aggressive. Interventions include providing physical and verbal cues to alleviate anxiety and give positive feedback. Document observed behaviors and attempt interventions and behaviors. When the resident becomes agitated, intervene before agitation escalates. Guide way from source of distress, engage calmly in conversation. If the response was aggressive, the staff were to walk away calmly and approach later. The behavior note dated 11/7/23 at 10:47 a.m. documented in pertinent part, "The resident made verbal threats toward this registered nurse (RN) while rounding on him this morning. This RN left the room immediately to de-escalate the situation. Later this resident was apologetic towards this RN. Social services staff notified." The 72 hour follow up note dated 11/8/23 at 6:23 a.m. documented in pertinent part, "The resident stood in the door of his room wrapped in his blanket peeking down the hallway for a while during the night. He later came toward the rotunda and went down the blue hall entering another resident's room where he was caught just before attempting to get into an occupied bed. He was redirected back to his room where he stayed for about an hour. During this time, the CNA attempted to assist him with his clothing as he had his pants on backwards and he raised his hand at her and stated, 'Don't tell me what to do.' The CNA felt unsafe so she left the room. After she left he exited his room and went toward the rotunda. She exited another room and saw him attempting to enter a female resident's room. He was again redirected and brought to the rotunda and offered a snack and apple juice. He ate and then fell asleep in a recliner in the rotunda. The nurse note dated 1/3/24 at 7:53 p.m. documented in pertinent part, "Resident #2 wandered at night and was half way down the hall and a CNA came out of another room seeing Resident #2 was leaning over the other resident with his hands on his sweater to try and lift the resident up. Resident #1 was lying on the floor against the wall next to the wheelchair. Resident #1 was assisted by CNA to the rotunda. Resident #2 said, 'I was trying to help him up.' Resident #2 was observed to have redness/possible bruising to the right hand at the base of the third finger knuckle and abrasion on the back of his left hand." VI. Staff interviews CNA #1 was interviewed on 2/13/24 at 10:52 a.m. CNA #1 said Resident #1 did not like to go out of his room as he did not feel comfortable around others. She said the resident had his good and bad days but was good with her and she had no problems with him. CNA #2 was interviewed on 2/13/24 at 11:02 a.m. CNA #2 said she was familiar with Resident #2. She said the resident had a lot of behaviors especially when providing care. She said he would yell and cuss at staff and did not like to be bothered. She said she was not working any of the times any of the resident incidents happened but she was told of the resident to resident altercations between Resident #1 and Resident #2. She said the residents did not have any interventions or guidelines to follow that she was aware of to prevent further altercations. She said she would find out. CNA #2 was interviewed again on 2/13/24 at approximately 11:15 a.m. CNA #2 said the interventions for Resident #2 were to monitor him and keep him within line of sight. RN #1 was interviewed on 2/13/24 at 11:15 a.m. RN #1 said he was familiar with both Resident #1 and Resident #2 and was aware of the resident to resident altercations between them. He said the residents did not have any interventions in place. He said Resident #2 did not have any behaviors. The social service director (SSD) and NHA were interviewed together on 2/13/24 at 1:29 p.m. The SSD said he was the abuse coordinator for the facility. He said the resident to resident altercation on 11/7/23 between Resident #1 and Resident #2 was substantiated as it had been witnessed by staff. He said he was called into the facility for the second incident on 1/3/24. He said the two residents were found together and a CNA witnessed Resident #2 grabbing the collar of Resident #1 while he was on the ground. He said Resident #1 was sent to the hospital due to his injuries and Resident #2 had reported no injuries but after the nurse assessed Resident #2 he had some bruising ]and scraped knuckles on his hands. He said both residents were confused and they were not really "with it". He said the investigation identified Resident #1 was hit but he could not recall the specifics of the incident. The NHA said Resident #1 had short term memory because he could not remember what happened five minutes ago. She said Resident #1 could not recall the incidents but would not say what really happened.

A revisit survey was completed on 6/12/23 for all previous deficiencies cited on 3/16/23. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K000) are informational only and a representation of the facility's general characteristics. The facility is a one-story wood frame structure, Type V(111) construction, without a basement. The breezeway and associated attic space between the long-term care facility and the administration building is separated by two-hour fire rated construction. The facility and the administration buildings are protected throughout by a dry-pipe automatic fire sprinkler systems and is classified as Fully Sprinklered. The survey was conducted on March 29, 2023 using National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, Chapter 19 for Existing Health Care Occupancies.

Based on observation it was determined that the facility did not maintain the kitchen hood suppression system as required by NFPA 96 and NFPA 17A. Kitchen stove and cooking equipment missing wheel blocking and/or a means to ensure the appliance is returned to its design location. Nozzle caps blow off | Verification of agent distribution piping is not obstructed not completed during semi-annual inspections NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 17A 7.3.3.1(3) *Verification that the agent distribution piping is not obstructedThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the facilities director at the exit conference.

A recertification survey was conducted 3/13/23 to 3/16/23. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/13/23 to 3/16/23. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision and assistance devices to prevent accidents were provided for one (#27) of three residents reviewed for accidents out of 22 sample residents. Specifically, the facility failed to provide supervision during meals for Resident #27 who required supervision due to choking/coughing. Findings include: I. Resident status Resident #27, age 98, was admitted on 10/14/21. According to the March 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of the bladder, age related cognitive decline, bradycardia (slow heart rate) and anemia. According to the 12/15/22 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had physical behaviors directed toward others. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident required supervision for eating. The MDS assessment revealed swallowing disorder of coughing or choking during meals or when swallowing medications. II. Observations On 3/13/23 at 11:32 a.m., Resident #27 was sitting in the rotunda eating his lunch by himself. No staff were observed while the resident was sitting in his wheelchair eating his meal. The resident was observed to be vigorously coughing during his meal. Resident #27 continued to cough and started to gasp for air as he tried to catch his breath. Resident #27 continued to cough and he was unable to eat his meal. An unknown certified nurse aide (CNA) approached Resident #27 and asked him if he was done with his meals. The CNA placed the plate cover over the resident's plate and removed the plate taking it to the kitchen. The assistant director of nursing (ADON) was getting a drink of water in the rotunda and observed Resident #27 having difficulty and asked how he was doing. Resident #27 requested a cup of coffee which the ADON said she would get from the kitchen. On 3/14/23 at 11:29 a.m., Resident #27 was eating his lunch in the rotunda by himself. The nursing home administrator came from the Special Forces hall and exited the rotunda area. No other staff were observed in the area. Resident #27 again started to vigorously cough but was unable to clear his throat. Resident #27 continued to cough trying to clear his throat. Resident #27 was slumped over coughing trying to catch his breath. His eyes were shut tight as he gasped for air. This surveyor was going for assistance when a CNA #2 walked into the rotunda and observed Resident #27 choking. She asked Resident #27 if he was okay with which he did not respond. CNA#2 then asked Resident #27 if he got it out. CNA #2 then called registered nurse (RN) #1. RN #1 started helping Resident #27 to catch his breath. Resident #27 was spitting up into a napkin. RN #1 threw three napkins into the trash while observing the napkins content. RN #1 then requested Resident #27 to blow his nose to help him clear his airway. RN #1 continued to monitor Resident #27 and check vitals while ensuring the resident's safety. The director of clinical operations (DCO) was also assisting with Resident #27. -At 12:35 p.m. CNA #2 was observed coming out of Resident #27's room. The resident was lying in bed in a 30 degree incline and continued to have a cough. The DCO was sitting next to Resident #27 while he was resting in bed. -At 12:47 p.m. RN #3 was observed monitoring Resident #27 who continued to still have a cough. III. Record review The care plan, initiated 10/15/21 and revised 3/2/23, identified the resident had a chewing and swallowing problem. The resident would cough with beverages during meals or swallowing medication. Swallowing assessment results by speech therapy to evaluate. The resident refuses one-to-one care and assistance at times related to independence and right to self-determination. Interventions include diet to be followed as prescribed of regular mechanical soft, thin liquids, and may have regular diet as needed per resident's request. The resident had a risk benefit diet consent form signed and reviewed. Have resident sit at the assist table as needed. Monitor/document/report any signs or symptoms of dysphagia: pocketing, choking, Coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat, appears concerned during meals. Refer to Speech therapist for swallowing evaluation. Nurse log note dated 3/9/23 at 1:50 p.m. documented in part Residents complaining about resident's cough during meals times. Will follow up with an interdisciplinary team. Nurse log note date 3/14/23 at 12:45 p.m.., documented in part this resident coughing in the rotunda where he was having lunch. Was able to clear his secretions. Coughed off and on x 10 minutes while this RN had him under direct observation. Drank a little lemon lime soda and calmed himself. No signs or symptoms of distress, asked to return to his room. States that he is done with his lunch. Chatted with resident at his bedside x 10 minutes, respirations even and unlabored, and no signs/symptoms of distress. Was joking around with this RN and staff nurse. Denied any further needsNurse note date 3/15/23 at 11:35 a.m., documented in part the resident was offered snacks this morning in the rotunda. The resident chose potato chips. The resident began coughing and was given a soda. The coughing subsided and the resident did not want to give staff his chips, initially but later offered to give them up for another snack. Staff at the side of the resident during the entire event. The resident continues to be monitored. IV. Interviews RN #1 was interviewed on 3/14/23 at 1:15 p.m. RN #1 said she was familiar with Resident #27. She said Resident #27 would eat in the rotunda because it had been reported that he was disturbing other residents in the dining room with his excessive coughing. She said other residents were disgusted by his continuous coughing. She said Resident #27 had a history of aspiration as he chewed his food too fast and he choked. She said Resident #27 was very particular about his food and did not like anyone to touch his food. She said generally the facility would have staff close by for Resident #27 and would be in line of sight while he was eating in the rotunda. She said Resident #27 was spitting up chunks of broccoli and sputum while she was monitoring Resident #27. She said Resident #27 had a history of coughing but today obviously was much worse than normal. She said a negative outcome of not monitoring Resident #27 while he was eating in the rotunda could be life threatening. CNA #2 was interviewed on 3/14/23 at 1:29 p.m. CNA #2 said Resident #27 would eat in the rotunda as other residents were getting upset with his coughing and it was affecting the others during meal time. She said Resident #27 had a history of coughing and choking. She said this past Sunday 3/12/23, Resident #27 had a severe coughing fit while he was eating. She said she would make sure the resident was okay and then she would offer him a drink of Sprite. She said she was assisting another resident at the end of Blue heaven hall when she observed Resident #27 having a hard time with his meal. She said she observed the resident's plate and the broccoli was whole and the sweet potatoes were definitely not mechanical soft size. She said she would compare the size of the food to a fifty cent piece. The social service director (SSD) was interviewed on 3/14/23 at 1:31 p.m. He said Resident #27 eats in the rotunda on a daily basis but that was his preference. He said Resident #27's medical power of attorney (MPOA) requested Resident #27 eat in the rotunda. He said Resident #27was supposed to be in line of staff while eating in the rotunda. The physical therapist (PT) was interviewed on 3/14/23 at 1:48 p.m. He said Resident #27 eats in the rotunda because other residents would complain about his coughing. He said it was taking away the ability of others to enjoy their meals. He said Resident #27 had a history of aspiration and choking when eating his meals. He said therapy had tried on several occasion to do an evaluation with Resident #27 but Resident #27 would always be non-compliant and refuse any type of evaluation. So the facility medical power of attorney and the resident filled out a risk benefit form documenting Resident #27 had chosen to go against medical advice and not eat a pureed meal diet and thicken liquids taking full responsibility for his choices. He said Resident #27 should be in line of sight of staff and in a safe environment while eating his meals. The dietary manager (DM) was interviewed on 3/14/23 at 1:59 p.m. She said Resident #27 eats his meal in the rotunda due to complaints by other residents in the dining room about his coughing. The DM was told of the observation in the rotunda while eating and the size of the broccoli and sweet potatoes. She said the mechanical soft diet should be bite size pieces. She said she would educate dietary staff again on the procedure of special diets. She said a negative outcome of residents not receiving a correct diet could be choking and/or death. The DCO was interviewed on 3/14/23 at 2:13 p.m. She said she was somewhat familiar with Resident #27. She said, "It was my understanding that Resident #27 was to receive supervision or in line of sight and today he did not receive any while he ate." She said a negative outcome would be choking and aspiration. The ADON was interviewed on 3/14/23 at 2:24 p.m. She said Resident #27 was asked daily if he wanted to eat in the dining room in the rotunda. She said he was independent with eating his meals. She said staff were always in the area of the rotunda and staff who were in their offices who would hear anyone if they were choking. She said Resident #27 did have a history of coughing and he did have one episode of aspiration and the staff did keep an eye on him during meals. The ADON was told of the observation above of Resident #27 coughing/choking while he was eating his meals and no staff responded until CNA #2 came into the rotunda. The ADON said Resident #27 could not be identified as aspirating as aspiration required a diagnosis by a physician. She said Resident #27 had such a strong cough he could clear himself most of the time. The ADON said Resident #27 was to be in line of sight of staff while eating but it was not always 100 percent of the time. The NHA was interviewed on 3/14/23 at 3:45 p.m. She said Resident #27 had the option of eating in the dining room or the rotunda but he liked eating in the rotunda. She said Resident #27 had the right to choose where he wanted to eat and if he was having a coughing episode he also had the option of going to his room. She said the facility would ensure he was safe while he was eating. She said Resident #27 had signed a risk benefit statement form choosing to not eat a puree diet and he chose what he wanted to eat. She said he would not sit at the assisted dining table either and that was his choice. She said a negative outcome of not having supervision or in line of site during meals Resident #27 could get pneumonia, choke and/or death. The registered dietitian (RD) was interviewed on 3/17/23 at 4:32 p.m. via telephone after exit. She said she was familiar with Resident #27. She said Resident #27 had a history of excessive coughing, choking and aspiration. She said Resident #27 refused to eat a pureed meal and chose to eat what he wanted to eat. The RD said if the resident was eating at the assisted table or in the dining room, he should be monitored. She said if Resident #27 was eating in the rotunda he should have definitely been monitored closely by staff. The RD was told of observations above during lunch and the size of the resident's food. The RD said the mechanical soft food should be bite size and not whole pieces of broccoli and sweet potatoes.

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#15) of four residents reviewed for supplemental oxygen use out of 22 sample residents. Specifically, the facility failed to ensure physician's order was in place for Resident #15's continuous oxygen use. Findings include:I. Facility policy and procedures The Oxygen Therapy policy and procedure, revised February 2/23/23, was provided on 3/14/23 at 4:00 p.m., by the nursing home administration (NHA). It read in pertinent part, "It is the policy of the (name of the facility) that oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the residents' goals and preference. It is the policy of this facility to administer oxygen in a safe manner."II. Resident statusResident #15, age 86, was admitted on 4/21/21. According to the March 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease, sleep apnea, and dementia. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The resident had no behaviors. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. The MDS assessment revealed the resident did not receive oxygen therapy. III. Record review The care plan, initiated 4/21/21 and revised 3/9/23, identified the resident had COPD. Interventions include the resident refusing to wear oxygen during the day. Continuous positive airway (CPAP) discontinued on 11/17/21. The resident refuses to wear oxygen discontinued on 6/23/22. The April 2022 CPO included an oxygen order for O2 at 2 liters per minute (LPM) via nasal cannula. Check oxygen saturation (SAT) daily. Notify a medical doctor (MD) if SAT is lower than 89%. Discontinued 4/18/22.-The March 2023 CPO did not include a physician's order for oxygen. IV. Observation and interviewOn 3/13/23 at 10:46 a.m., the resident was lying in bed with no oxygen on. Resident #15 had an oxygen concentrator and CPAP machine at the foot of his bed. No oxygen tubing or nasal cannula were observed.-At 3:30 p.m. Resident #15 was observed sleeping in bed with no oxygen on. On 3/14/23 at 9:00 a.m., the resident was lying in bed with no oxygen on. On 3/15/23 at 3:04 p.m. Resident #15 was lying in bed sleeping. He had oxygen at 2 liters per minute (LPM). Registered nurse (RN) #3 observed Resident #15 lying in bed sleeping with his oxygen on. RN #3 said Resident #15 always slept with his oxygen on. RN #3 said Resident #15 had an order for oxygen while laying down in bed. RN #3 was shown the discontinued order for resident's oxygen and CPAP. RN #3 walked to his medication cart and reviewed the resident CPO. RN #3 said Resident #15 should have had a physician's order prior to the use of continuous oxygen. He said he would get the physician order updated. V. Staff interviews The ADON was interviewed on 3/15/23 at 2:24 p.m. She said, "I don't consider oxygen to be a medication because as a nurse I can put oxygen on a resident if they need it." She said the facility missed the order and the oxygen was ordered for Resident #15.

Based on observations, record review, and interviews, the facility failed to provide special eating equipment and utensils for residents who need them for one (#20) of two residents reviewed for adaptive equipment out of 22 sample residents. Specifically, the facility failed to ensure the physician ordered weighted utensils, Dycem placement, sippy cup and scoop plate was positioned correctly during all meals for Resident #20. Findings include: I. Resident status Resident #20, age 79, was admitted on 3/29/21. According to the March 2023 computerized physician orders (CPO), diagnoses included Parkinson's, gastro-esophageal reflux disease and chronic kidney disease. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had wandering behaviors. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. The MDS revealed the resident required supervision, encouragement and set up for meals. B. Record review The care plan, initiated 3/29/21 and revised 3/9/23, identified the resident had nutritional problems related to Parkinson disease, dysphagia (swallowing difficulty), difficulty chewing and risk for weight loss. Intervention included:Monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. Provide, serve, diet as ordered. Regular mechanical soft thin liquids. Monitor intake and record meals. -The resident did not have a care plan identifying use of assistive devices. The March 2023 CPO included:For all meals and snacks: weighted utensils with built-up handles, scoop dish, Dycem placemat, and sippy cup with handles. Revision date 4/24/21. C. Observations On 3/14/23 at 11:53 a.m. Resident #20 was in the main dining room eating his lunch. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the two o'clock position. Resident #20 was right hand dominant and was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate.-At 4:32 p.m. Resident #20 was observed in the main dining room eating his dinner. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the three o'clock position. Resident #20 was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate. On 3/15/23 at 11:43 a.m. Resident #20 was observed in the main dining room eating his lunch. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the 12 o'clock position. Resident #20 was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate. IV. Interviews Registered nurse (RN) #3 was interviewed on 3/15/23 at 11:51 a.m. RN #3 observed Resident #20's plate. RN #3 said the high lip of the resident's scoop plate was at the top of the scoop plate. RN #3 said he was not familiar with the correct placement of the scoop plate but would check on its placement. Certified nurse aide (CNA) #9 was interviewed on 3/15/23 at 11:59 a.m. She said Resident #20's scoop plate should have been at the left side of the resident. CNA #9 said, "I changed it to the correct position." CNA #9 said dietary staff would serve the residents' meals and sometimes would just place them in front of the residents. CNA #9 said she was aware Resident #20 utilized a scoop plate but was not aware of the other assistive devices. The dietary manager (DM) was interviewed on 3/15/23 at 3:17 p.m. She said the dietary staff are aware of any assistive devices required for all residents. She said Resident #20 should have been provided with all assistive devices to ensure adequate food intake during all meals. She said he would provide training for the dietary staff immediately. The registered dietitian (RD) was interviewed on 3/17/23 at 4:32 p.m. via telephone after exit. She said she was familiar with Resident #20. She said the dietary department had all of the assistive devices and should have been using them. The RD was told of the observations above. She said, "That doesn't make sense." She said Resident #20 was not getting 100 percent of his meal and it probably was taking longer to eat. She said a negative outcome would be his food getting cold and losing its palatability and possible weight loss.

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure:-Appropriate hand hygiene by food service staff; and, -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. "Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by;2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device." B. ObservationsOn 3/13/23 at 8:41 a.m., dietary aide (DA) #1 was preparing French toast. She grabbed four slices of bread and held each piece of bread on her palm. She proceeded to use a brush to put the egg mixture onto the bread. She repeated this for all four slices of bread. She used her gloved hand to place them onto the grill and reach over and grab a spatula. She allowed the French toast to cook and while grabbing a plate and continuing serving meals. She then wiped her gloved hand on the side of her pants. DA #1 did not perform hand hygiene during this process. Observation of the meal service was conducted on 3/15/23 at 10:47 a.m. The cook was observed preparing mechanical soft and puree meals. The cook went toward the front of the kitchen and retrieved several cans of soup. The cook grabbed several slices of bread to add them into the pureed meal. The soup cans had a flip top lid. She opened the can of soup and placed the contents in the blender. She then moved over to the trash can and utilized her forearm to lift the lid of the trash can and discarded the can. She returned to the puree station and proceeded to puree the broccoli soup. She then reached down and retrieved a small metal pan and proceeded to spray the metal pan with spray oil. She then poured the soup into the metal container and placed it on the counter in front of the oven. The cook was wrapping the metal container with aluminum foil. The temperature of the soup was going to be taken. She proceeded to grab a thermometer and several sanitizing wipes. She took the temperature of the soup and then wiped the thermometer with the alcohol wipe. She wrapped the soup with aluminum foil and reached into her pocket and grabbed a marker. She wrote soup on top and grabbed the oven handle with her hand and placed the small container into the oven. She then grabbed the used alcohol wipes and again lifted the trash can with her forearm and discarded the wrappers into the trash. She proceeded to remove the blender container and placed it into the sink. She ran water into the blender container. She then grabbed a metal container of mixed vegetables and poured them into another blender container. The cook did not perform hand hygiene during this process. DA #1 was observed entering the kitchen from the dining room and going directly to the washed dishes on the south side of the dishwasher. She started removing clean dishes and placing them on the clean metal rack. DA #1 again exited the kitchen and returned to the clean dish area and proceeded stacking the clean dishes on the metal rack. DA #1 did not perform hand hygiene during this process. DA #2 entered the kitchen from the dining room. She proceeded to the large mixer and started to make a whipped topping for a cake she was preparing. She placed all ingredients into the metal bowl and proceeded to mix the ingredients. She went to the shelf and grabbed a small container of food coloring and placed several drops into the mixing bowl. As she was leaning over into the mixing bowl her lanyard went into the bowl. DA #2 grabbed her lanyard and flipped it toward her back. She then proceeded to grab a large metal bowl and proceeded to scrap the whipped topping into the bowl. She placed the bowl onto the counter and wrapped it with plastic wrap. She reached into her pocket and grabbed a marker and wrote the date on top. She grabbed the handle of the walking and placed the container into the walk-in refrigerator. She removed all the metal whisk and metal bowl from the mixer and proceeded to take the items to the dishwashing area. She proceeded to rinse them and placed them into the dishwasher. She exited the kitchen area again and returned removing the whisk and the metal pan. She returned to the mixer and reinstalled all of the items. DA #2 did not perform hand hygiene during this process. DA #1 was observed making a peanut butter and jelly sandwich. She grabbed a bag of bread and removed two slices of bread with her gloved hand. She proceeded to walk in front of the serving line and grabbed several containers of peanut butter. She returned to the serving line and proceeded to make the sandwich. She placed a slice of bread onto her gloved hand and then opened the container of peanut butter. She grabbed a table knife and spread the peanut butter on the bread while in her gloved hand. She repeated this on the other slice of bread. She then placed the sandwich on the large cutting board and grabbed a knife and cut the sandwich into two pieces. She grabbed the sandwich with her gloved hand and proceeded to place them on a plate on the shelf of the serving line. DA #1 did not perform hand hygiene during this process. DA #1 was observed preparing a hamburger for meal time. DA #1 was observed grabbing a hamburger bun out of the bag with her gloved hand. She placed the hamburger bun onto the large cutting board. She then grabbed a slice of cheese with her gloved hand from the sandwich preparation area and placed it on the bun. She then grabbed the hamburger and placed it onto the bun with her gloved hands. She grabbed the hamburger with her gloved hands and proceeded to place it on the plate. She then grabbed a pair of metal tongs and placed some French fries onto the plate and placed it on the top shelf of the serving line. DA #1 did not perform hand hygiene during this process. C. Staff interviewThe dietary manager (DM) was interviewed on 3/15/23 at 3:17 p.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. She said staff should never touch ready to eat foods with their bare hands. She said they should use serving tongs even if they have gloves on. Staff should also wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination. II. Food temperaturesA. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 "Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds." B. Observations and staff interview On 3/15/23 at 10:47 a.m., the cook was observed preparing mechanical soft and puree meals of broccoli cheese soup, mixed vegetables and lasagna that was being held for lunch service. The cook proceeded to the front of the kitchen and retrieved several cans of mushroom soup. She placed them into the blender and proceeded to puree the broccoli and cheese soup. She grabbed a small metal container and sprayed it with cooking oil. She poured the pureed soup into the metal container and placed it on the container. She proceeded to start wrapping aluminum foil on the container. The surveyor requested for the cook to take temperatures of the puree food. The cook stated the temperature of the soup was 124 degrees F. She then placed it into the warming oven. She proceeded to complete the same process for the mixed vegetables. After she was done pureeing the mixed vegetables she placed them in a small metal pan and took the temperature of the mixed vegetables, which read 106 degree F. She wrapped them with aluminum foil and placed them into the oven. She then placed four large pieces of lasagna into the blender and proceeded to pure the lasagna. After getting it to the correct consistency she grabbed another metal pan and poured the puree into the pan. She placed it on the counter and took the temperature, which was 129 degrees F. She wrapped it with aluminum foil and placed it into the oven.-At 11:05 a.m., the cook was asked if she checked the temperature of the pureed foods after pureeing them. The cook said, "No, I do not, but I would take the temperatures before serving them." -At 11:22 a.m., the cook took the temperatures of the broccoli and cheese soup, mixed vegetables, and the lasagna. The temperature of the broccoli cheese soup was at 123 degrees F. The mixed vegetables was 131 degrees F, and the lasagna was at 143 degrees F. -At 11:31 a.m., the cook again took the temperature of all items listed above. The broccoli and cheese soup was at 167 degrees F. The mixed vegetables temperature was at 169 degrees F, and the lasagna was at 170 degrees F. C. Additional interview The DM was interviewed on 3/15/23 at 3:17 p.m. She said she was aware that the temperatures of the modified food dropped at times. She said "It's my expectation that the food was ok as long as it reached 165 degrees F before serving." She said dietary staff would be educated immediately to ensure the modified consistency food reached proper temperatures and time frames.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for three (#91, #38 and #25) of five residents reviewed for vaccinations of 29 sample residents. Specifically, the facility failed to ensure Residents #91, #38 and #25 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC), reviewed 11/21/22, retrieved on 3/27/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, "If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged 65 years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March." According to the CDC Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 3/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part,"The pneumococcal vaccine was to be administered to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. "For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-64 years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23." II. Facility policy The Pneumococcal Vaccine policy, revised 12/20/22, was provided by the nursing home administrator (NHA) on 3/15/23 at 1:01 p.m. the policy included, "Policy:Facilities will offer and provide vaccinations against pneumococcal diseases in accordance with the (CDC) recommendations and guidance. Procedures/Process: -Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine the date of immunization or type of vaccine received. -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved 'standing orders.' -Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization.a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine.b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. -The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. -The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. -Usually only one (1) pneumococcal polysaccharide vaccination (PPSV) is needed in a lifetime. However, based on an assessment and practitioner recommendation, additional vaccines may be provided. -A pneumococcal vaccination is recommended for all adults 65 years' and older and based on the following recommendations:a. For adults 65 years' or older who have not previously received any pneumococcal vaccine:Give 1 dose of PCV15 or PCV20.i. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. Theminimum interval is 8 weeks and can be considered in adults with an immunocompromisingcondition, cochlear implant, or cerebrospinal fluid leak.ii. If PCV20 is used, a dose of PPSV23 is NOT indicated.b. For adults 65 years' or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20.i. The PCV15 or PCV20 dose should be administered at least one year after the most recentPPSV23 vaccination.ii. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it.c. For adults 65 years' or older who have only received PCV13: Give PPSV23 as previouslyrecommended. -For adults 19 to 64 years' old who have only received PPSV23: Give 1 dose of PCV15 or PCV20.a. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination.b. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. -For adults 19 to 64 years' old who have received PCV13 with or without PPSV23: Give PPSV23 as previously recommended. -The resident's medical record shall include documentation that indicates at a minimum, the following:a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization.b. The resident received the pneumococcal immunization or did not receive due to medicalcontraindication or refusal." III. Resident #91 Resident #91, age 90, was admitted on 2/24/23. The medical record revealed the resident received the influenza vaccination outside of the facility and his pneumococcal vaccination information provided prior to admission had been documented non compliant. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #38 Resident #38, age above 90, was admitted on 12/28/22. The medical record revealed the resident received the influenza vaccination at the facility and his pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Resident #25 Resident #25, age 86, was admitted on 3/30/22. The medical record revealed the resident received the influenza vaccination at the facility and her pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. VI. Interview The director clinical operations (DCO) was interviewed on 3/14/23 at 4:00 p.m. She said when the request was made for vaccination records, the facility had identified the problem with pneumococcal vaccination status. She said the facility was currently conducting an audit of the residents and would be contacting the providers. She said it would be important to offer the vaccine to help prevent pneumonia.